Healthcare Provider Details

I. General information

NPI: 1841263142
Provider Name (Legal Business Name): JOHN BASTIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WATER STREET
BLUE HILL ME
04614
US

IV. Provider business mailing address

57 WATER STREET
BLUE HILL ME
04614
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone: 207-374-3911
  • Fax: 207-374-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-652
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110037
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: